Counting the true death toll

The World Health Organization estimates 4.7 million Indians died of Covid-related causes through 2020 and 2021. The Indian government estimates the death toll from Covid was about 481,000. The semantics of “Covid” and Covid-related” aside, the 10X discrepancy is too large to ignore.

Arguing about the data leads into a political battle because the government feels it is bad for its image to admit to a massive death toll. That is a pity because the controversy about the data has arisen largely because of holes in the data-collection apparatus. What’s more, the largest and the most-backward of states, where the largest number of mortalities occurred, have the least efficient data-collection systems.  

In normal circumstances, the Civil Registration System, or CRS, records 70-80 per cent of all deaths. Only about one in five of the deaths recorded comes with a death certificate that lists a cause of death. Matching the CRS data to the Census data makes it apparent that around 20 per cent of deaths are not registered.

When somebody dies, there may or may not be a medical death certificate. There will be a receipt issued by the crematorium or cemetery where the body is disposed of, and the details will be entered in the register of that institution. The family can present that receipt at the relevant panchayat or municipality, and collect a pucca certificate, which is useful for legal purposes.

If there is nothing to inherit, the heirs often don’t bother with this paperwork. In that case, the death may not show up at all in CRS statistics. Not all municipalities and panchayats bother to collate the registers of crematoriums (many of these are not online) and cross-check versus the pucca certificates. If the body is just chucked into a river, or interred in the mud, the death will not show up at all. As we all know, a lot of bodies were chucked into rivers in 2021.  

A medical certificate isn’t necessary to dispose of a body. This is pragmatic, given the low proportion of qualified medical practitioners to population. If a medical document is issued (which is in around 22 per cent of cases) it will rarely list a detailed reason. Covid-related deaths could be put down to generic causes like heart-failure, organ failure, congestive heart failure, pulmonary edema, etc., which tell you nothing much about the underlying cause.

Circumstances were anything but normal these last two years. Thus, it’s likely that a far larger proportion of deaths went unrecorded. The CRS for 2020 records “excess deaths” to the tune of 475,000. We don’t have the CRS data for 2021, which means there is no official single source for data about the death toll of the second wave.

By 2020, India had the capacity to dispose, with basic dignity, of about 30,000 corpses per day, in various facilities spread across 750-odd districts. During the second wave, those facilities were stretched to the point where there were usually delays of 12 hours or more, and excess corpses were being thrown into rivers, or buried on river-banks.

There are several estimates made by different organisations and individuals estimating Covid-related deaths in India exceeded a minimum of two million. Those estimates also indicate the bulk of Covid-related deaths occurred during the second wave in April-May-June 2021.

Those estimates draw on data from diverse sources, including the CRS, crematorium records, obituary notices in papers, municipal requisitions for wood for crematoriums, insurance claims, etc. The models used match those data to historical records, and extrapolate excess deaths. Every study indicates massive under-counting. The known lacunae in the CRS and the widespread anecdotal evidence make those estimates look more credible than the official claims.

Politics and image management apart, this gap in data collection needs to be plugged. You cannot make effective healthcare policy, if you don’t know how many people die each year, and from what causes. But the government’s defensiveness about its image may lead to great reluctance to improve the collection process, and even greater reluctance to make the data public even if systems do improve.